[ BLOG ] : A brief window to intervene and shape the future of health IT in Australia … it’s closing soon

The issue of fit between the work and needs of clinicians (medical, nursing and other) together with the clinical information systems (CIS) they are expected to use during the course of managing patients, is one that has been gaining increasing amounts of attention over time. This is particularly true of large-scale CIS. That is to say, Electronic Medical Record systems (EMRs).

In fact I’d argue that the attention this issue has garnered on the international stage has increased proportionately to the increase in the number of clinicians routinely using such systems. Of course, that number of clinicians will no doubt bear a direct relationship to the number of CIS installations. Even the head of IT at a major international EMR vendor has acknowledged this issue, as has the Office of the National Coordinator for Health IT (the ONC) in the US.

What is now quite clear is that there is a worrying amount of discontent amongst many clinicians as to the LACK of fit between their needs and work practices, and what many of these systems or implementations allow. This lack of fit is manifest in complaints of, and evidence around, clinician dissatisfaction, patient safety risks, excessive (system driven) workload, excessive cognitive load, and undue complex system interactions (including unduly complex navigation/ interaction patterns).

In turn there are anecdotal reports of – and evidence around – resultant: clinician burnout with this lack of fit and related frustration as the source of: actual patient safety events, malpractice claims / prosecutions, clinicians developing workarounds to bypass systems or some of their intended functions and various other outcomes. The AMA in the US is responding to this burnout problem at a programmatic level through their “Steps Forward” program.

There are MANY, MANY reasons for this apparent lack of fit. It’s a PhD-worthy topic several times over in fact. One set of reasons are those outlined recently by Lintern and Motavalli.

In short – there is an issue – this is clear. Some of the major international EMR vendors are responding to this issue. For example, by changing software design philosophies (e.g. – responsive design built-in as a core approach to product development) including, efforts to boost their internal capability around usability and user experience (UX) (personal communication).

What I think is a much greater and more interesting issue therefore is, how do we as a healthcare industry respond to this very important and global challenge?

For those deeply interested in this topic, I’d suggest that they read a recent article in the Communications of the ACM by Andriole (Dec 2017; Vol 60. Num 12 pp 29-32). Despite this being an IT professional magazine, it’s not a hard read for the non-technical amongst us. Interestingly in this article entitled “The Death of Big Software”, the author is speaking from an industry agnostic perspective. Yet much of what he is saying rings true in relation to the history of CIS’ in healthcare and the core issue of lack of fit outlined above.

Without repeating the entire article, the following key quote says much about the main message of the author… “Software architectures must be blank canvases capable of yielding tiny pictures or large masterpieces”. Whilst such quotes have a tendency to grossly oversimplify the ENORMOUS complexity of building non-trivial software systems, there is a core truth in this statement in my view. I believe that heading in this direction is ONE key way to address the lack of fit described earlier.

Alternate system development approaches and architectures have also been created as one way to address these issues. See the work of Prof Jon Patrick and his team who have built greater configurability – by clinicians – into their core system architecture.

The rise of FHIR, APIs and “ecosystems” is to be commended and should offer some assistance but this may also bring unintended issues around integration of workflows with implications for usability and UX. This is one down side to a “best of breed” approach to CIS’.

Involving clinicians in all stages of the software development/deployment lifecycle (SDev/DepLC) is critical. However, from my experience, current and former clinicians have already been involved for a long, long time inside medical software companies. I don’t believe that the solution is as simple as “adding more clinicians” to the processes. When it comes to health IT clinicians are DEFINITELY NOT a homogenous group by any measure. I could easily write an entire separate paper on this issue of clinician engagement with, and contributions to, these processes. It’s a very complex issue. Lintern and Motavalli offer some valuable insights on this very point – the RIGHT people with the RIGHT skills need to be involved in all parts of the various SDev/DepLC processes.

What can be done?

Educate vendor employees, many of whom already know about these issues and the relevant knowledge bases. But also educate healthcare employees, clinical informatics teams, participating clinicians, IT departments and executives about usability and UX will have some impact especially where systems or implementations allow their subsequent input to affect outcomes in this space.

Whilst there are some usability standards specifically pertaining to CIS’, more functionally- oriented CIS usability and UX standards (or at least some agreed measures to start with !!!) are also important here. This is where clinicians can have a key role.

Let me use a simple example to explain further. I’m aware of a major tech organisation that in recent years (this tech, in different forms, is now widespread) set about developing a rapid tap-on, tap-off PC access system (to avoid the constant typing of passwords as clinicians move between PCs, for example on a ward round).

The idea is, the clinician walks up to a PC and can tap a card on a device plugged into the PC. This action automatically authenticates them on the network and they are logged on to that PC. The stated benefit was to achieve system access (the clinician being able to use the PC) within 10 seconds of the clinician standing in front of the machine and tapping on. So, in this case, THIS key feature (10 sec measure) of the usability of the tech was the primary goal around development… and it was achieved.

If we now relate this example back to a typical CIS SDev/DepLC process. The system requirement would have been expressed as: “the system shall allow the clinician to obtain tap on access through use of an authentication card” or similar wording with no reference to the speed aspect. Not surprisingly, vendors have built and sold to such functional specifications and at a macro level, the industry has historically accepted that as a standard.

The use of such usability and UX standards, tied to procurement processes (“how well / quickly / satisfactorily can the system do X” vs “can the system do X”) should have a role in addressing the poor fit outlined earlier.

CIS procurement approaches to date have been far too focused on pure functionality, corporate risk and cost. Yes, these things are important although the balance is currently “out of whack” and we need to collectively push for MUCH greater integration of usability and usability standards into procurement processes.

Of late even more information has come into the public domain in the form of public anecdote, commentary and research on this topic all of which continues to point to the issues caused by poor usability of EMR systems and the resultant suboptimal user experience.

When set in the Australian context it should give us even greater cause for concern.

I make that statement for 2 reasons. Firstly, despite recent announcements about some Australian hospitals being certified at HIMSS EMRAM Level 7 as well as many ongoing EMR projects around the country, which by the way we welcome with open arms, we are still fairly early in our EMR journey when viewed from a national perspective. So ahead of us lays a great opportunity to take the lessons of more advanced nations about the usability and impact of EMRs on clinical staff and the healthcare system and avoid making exactly the same mistakes. Unfortunately, I see no obvious evidence of that happening however.

Secondly, and of greater concern is that this apparent inability or unwillingness to incorporate the lessons of others into how we implement and manage EMRs is set against the backdrop of an exceedingly low-level knowledge about UX and usability across the healthcare sector. These 2 phenomena can obviously be quite related!!!

So after conceiving of and setting up the HISA UX CoP almost 3 years ago, I have given probably several dozen talks on this topic and made numerous efforts to get the message out in social media about these issues. What is very apparent though, is that even audiences literate in health information or health IT have very little awareness of the knowledge bases underpinning usability and UX. Many have never heard of Nielsen and his heuristics, as one fairly scary example. These “co-located” phenomena should – unfortunately- continue to give us much cause for concern.

The US spent (I believe) $40 billion USD in a push for EMR uptake across their country and now EMRs are almost ubiquitous there. But many usability and UX problems have resulted, as I have outlined above. The ONC openly acknowledges this and states that usability is in their top 2 Health IT issues to be resolved (along with Interoperability… and we all know THAT pain).

So the challenge is in front of us. In effect it’s a long battle to be fought on multiple fronts and which needs to be fought in collaboration with all relevant parties including clinicians, informatics and IT professionals, vendors, funders and other relevant parties. Will we collectively fight that battle or will we, VERY UNNECESSARILY in my view, learn these lessons AGAIN ourselves? Can’t we take an easier path?

Professor Chris Bain

Professor Bain is an experienced clinician (former) and health IMT practitioner with a unique set of qualifications, and a unique exposure to broad aspects of the healthcare system in Australia. He also has extensive experience in designing, leading and running operational IMT functions in healthcare organizations. His chief interests include the usability of technology in healthcare, data and analytics, software and system evaluation, technology ecosystems and the governance of IT and data.

* ACADEMIC INSTITUTIONAL MEMBERSHIP eligibility criteria: AIM is for tertiary institutions that have health informatics programs or courses (teaching and/or research) – does not need to be specifically named HI course, e.g. public health, health information management etc. is ok. Provides HISA memberships for all faculty and higher degree by research students (Masters by Research or PhD students).

Introducing the Health CXIO Network!

The CXIO Network aims to provide a common platform for clinical leaders in digital health to share information – from innovations to emerging clinical issues and solutions – in order to deliver improved patient care.

HISA and HIMAA have recommended health informatics and health information management expertise is present at all levels of governance within a proposed Australian Commission for Electronic Health (ACeH).

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This publication is the second volume in HISA’s Thought Leadership Series. It represents a compilation of the content presented at the conference, as well as themes raised in discussions and networking. We thank Nigel Chartres who has authored this report and all presenters and attendees who contributed directly and indirectly to the content.

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This publication is the inaugural volume in HISA’s Thought Leadership Series. It represents a compilation of the content presented and the discussions held at Data Governance 2011. We thank Nigel Chartres who has authored this report and all presenters and attendees who contributed directly and indirectly to the content.

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This position statement has been developed to recognise the pivotal role of nurses in the widespread implementation and adoption of digital health technologies throughout the healthcare sector for the primary purpose of improving safety and quality of patient care. The successful planning, implementation, management and sustainability of such technologies cannot be achieved without the unique contribution of nurses.

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The competencies set the minimum requirements in terms of skills, knowledge, understandings and capabilities that will enable a candidate to perform in a professional environment. The competencies serve to define what health informatics professionals know and do. This framework can also be used as a set of guidelines for recruiting purposes, definitions of career pathways, or the design of educational and training activities.

They provide the context in which the questions for the CHIA exam have been developed.

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The Guidelines serves as a resource to assist the health sector as a whole, and especially healthcare professionals, to protect the personal health information (PHI) they require to do their work, and to meet their role and responsibilities.

They describe key security and privacy issues faced by healthcare organisations and offers guidance for responding to these issues. It is not an all-encompassing guide on the protection of PHI; rather, it is designed as a stepping stone to help healthcare organisations address common concerns, avoid confusion, and prevent misunderstandings. http://healthprivacy.org.au/

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Will your digital health implementation be a success story? How will you make sure your digital health implementation is safe?

The Australian eSafety Professional Practice Guidelines are being released for trial implementation initially, as it is important to acknowledge that patient safety in relation to digital health systems is a topic that continues to evolve, with a growing evidence base and emerging best practices being applied in a number of countries and jurisdictions. The guidelines are the first publication specifically tailored for the Australian digital health sector.

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PDF Copy: Packaged ZIP file, includes 3 PDF files

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A comprehensive body of knowledge that focuses explicitly on the needs of practitioners in the field of health informatics in Australia. It also covers the competencies tested in the CHIA exam; a valuable asset for CHIA candidates.

The Practitioner’s Guide has also been developed with other purposes in mind, including orientation for professionals such as clinicians or ICT professionals new to health informatics and updates for health informaticians wishing to maintain the currency of their knowledge, irrespective of certification.

If you purchased the first edition of A Practitioner’s Guide to Health Informatics in Australia, please email [email protected] for a special price to purchase the second edition.

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In the issue of the Medical Journal of Australia published just prior to the November 2007 election, a number of commentators including the Federal Minister and Shadow Minister reflected on the Australian health system and their plans for its future. The members of the Health Informatics Society of Australia (HISA) believe there is a yawning gap in this analysis both in terms of the size of the problem and how it might be fixed.

Author: HISAYear: 2007Pages: 73

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On behalf of Australia’s digital health community, HISA commends this submission to the Sustainable Health Review Panel, and wish them well in their deliberations. Our Board and members would welcome further involvement in the review process, either within the Panel’s current terms of reference or beyond.

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The Health Informatics Society of Australia (HISA) made a proposal to the E-Health Branch of the Australian Department of Health and Ageing (DoHA) that a review of the health informatics workforce be undertaken and were subsequently contracted to „prepare a background discussion paper which sets out the scope and structure of the health informatics workforce and draw together a summary of the key issues, gaps and opportunities for further work to be undertaken on this issue’. This then is a scoping study.

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The Australian Healthcare and Hospitals Association (AHHA) has convened three groups of experts, clinicians and academics to develop practical policy options across a range of areas.

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Australian Government Budget 2008-09 Summary of e-Health and health information measures.

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Late 2006 CQU established the electronic Journal of Health Informatics (eJHI) with a large international editorial board.

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In the issue of the Medical Journal of Australia published just prior to the November 2007 election, a number of commentators including the Federal Minister and Shadow Minister reflected on the Australian health system and their plans for its future. The members of the Health Informatics Society of Australia (HISA) believe there is a yawning gap in this analysis both in terms of the size of the problem and how it might be fixed.

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